Usage of Modifier 24 and 59

Modifier 24 

An Unrelated evaluation and management service performed by the same physician or other qualified health care professional during a post-operative period use modifier 24 for E/M Services. (Never to a procedure) 

Modifier 24 is applied to two code sets, 

• E/M (Evaluation and management) services (99201-99499). 
• General ophthalmological services (92002-92014), which are eye examination codes. 

Appropriate Use of Modifier 24 

• An unrelated E/M service is performed beginning the day after the procedure, by the same physician, during the 10 or 90-day post-operative period.  
• Documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care.
• Unrelated critical care performed by the same physician during the post-operative period. 

Inappropriate Use 

Do not use Modifier 24 when, 

• The E/M is for a surgical complication or infection. This treatment is part of the surgery package. 
• The service is removal of sutures or other wound treatment. This treatment is part of the surgery package. 
• The surgeon admits a patient to a skilled nursing facility for a condition related to the surgery. 
• The medical record documentation clearly indicates the E/M is related to the surgery. 
• Outside of the post-op period of a procedure. 
• Services are rendered on the same day as the procedure 
• Reporting exams performed for routine postoperative care. 
• Reporting surgical procedures, labs, x-rays, or supply codes. 

Example 1 

A Cardiologist was implanted Pacemaker Implantation on Dec. 26th due to complete Heart Block, and the patient returns with Chest pain and diagnosed as angina on Jan. 10th.  

The Jan. 10th visit is separately reportable with appropriate level of service codes with modifier 24, since it’s unrelated to the original procedure performed Dec 26th.  

Modifier 59 – X (E, P, S, U) 

“Distinct Procedural Service” - Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. 

The Centers for Medicare & Medicaid Services (CMS) established four (4) new HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported. 

XE – “Separate encounter" A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service. 

XS – “Separate Structure" A service that is distinct because it was performed on a separate organ/structure.

XP – “Separate Practitioner" A service that is distinct because it was performed by a different practitioner.

XU – “Unusual Non-Overlapping Service", the use of a service that is distinct because it does not overlap usual components of the main service.

• Modifier 59 should also only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes.
• The 59 modifier is one of the most misused modifiers. The most common reason it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body. 
• Modifier 59 should not be appended to an E/M service. 

Examples: 

Modifier XU 

• If Cardiac Cath (93454 to 93461) & PCI (92920 to 92943) procedure performed together during the same visit. We can bill with modifier XU for Cardiac Cath Procedures (column 2 codes). 

Modifier XE 

• If the mentioned above procedures are performed in two different encounters, the claim must be billed with modifier XE for Cardiac Cath CPT codes. 

Modifier XP 

• For mentioned above procedures are performed two different providers’, bill the claim with modifier XP. 

Modifier XS 

• For same procedure performed in two different location and or anatomical site we can use modifier XS for same CPT code if there are no anatomical site modifiers applicable, (Like RT & LT) 
• Injection into tendon sheath, right ankle (20550) and injection into tendon sheath, left ankle (20550- XS). 

Note: Medicaid & Medicaid HMO’s would not be accepted Anatomical site modifiers and or HCPCS modifier, so please use modifier 59 instead of X (E, P, S, U) and or not required HCPCS modifier, like RT, LT, RC, LC, LD and etc...) 

Modifier Indicator: 

• 0: not allowed (ie, modifier -59 is not allowed under any circumstances; the code pair will not be paid separately); 
• 1: allowed (ie, coders may be able to append modifier -59 to differentiate between services provided; separate payment will be allowed); or 
• 9: not applicable (ie, no modifier is necessary, as the edit is inactive as of the posted date; services may be separately billable). 
  

 

Return to check modifier 25 & 57